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Open reduction of a fracture of the mandible
OPEN REDUCTION .lAlIES
OF A FRACTURE
1,. BRADLEY,
L).I).s.,
GREAT
&l.S.i).,
LAKES,
OF THE 31.%'.(
MANDIBLE
IhWP.)."
h,.
PEN reduction in the treatment of fractures of the mandible is extrcmel>. helpful in immobilizing badly displaced posterior fragment,s of the ascentling ramus. If closed reduction is not successful surgery accomplishes exact approximation of the fragments, with less displacements by abnormal musc:l~ pull. On Nov. 4, 1949, E. R. B., a ZO-year-old man, a corporal in the Cnit,ed St,aics Army, was admitted to the dental ward of the I:nited States Naval Hospital, St. Albans, Long Island, N. Y., with a diagnosis of compound fracaturr of t h(h mandible.
0
History of Present Illness.--The patient complained of pain ant1 suelliuz: at the left and right sides of the mandible dating from 8 :15 P.M. Nov. ‘1: 1MS, at which time he had been struck in the jaw by another man. While in his company barracks, the patient had given orders to another man, who struck him instead of carrying out the order. He reported to the Fort, I)ix, N. .I .. He was then sent. to the base hospital dispensary where he was examined. where roentgenograms were taken and he was placed on penicillin therapy. t1e was then transported to this activity via ambulance and admit,ted. Past History.-His past history was entirely irrelevant. He had the scarlet fever, which he said had c21us~cl usual childhood diseases, including deafness for about six years. He had sustainetl a fl~actured nose five ywr~ previously while playing football. Family History.-The patient’s father and mother were living ant1 weil. He had two sisters and three brothers who were living ant1 well. ( )IIC: l)rotll+t~ had arrested tuberculosis. Examination.-Examination revealed ecchymosis of the lower lid of the left eye and a swelling at the angle of the left side of the mandiblr extentlittg from the zygomatic arch to below the angle. The right side near the mrntnl area was slightly swollen. The motion of the jaw was limited. He could opc’n his mouth about 0.5 cm. with marked pain in the left mandibular third mvlal region. Oral hygiene was extremely poor with numerous carious teeth. ‘l’hc~rc The mandibular third molar was was a foul odor to the patient’s breath. elongated and loose. There was numbness of the distribution of the inierior alveolar nerve. Roentgenograms of the mandible showed an oblique fracture through the ramus at the angle of the left side of the mandible extending from the base of There was considerable diaphysis between the frapme~rts t,he third molar. The opinions or assertions contained herein are the private ones of the writer and not to be construed as official or reflecting the views of the Navy Department or the Naval Service at large. (Art. 13 [2] U. S. Navy Regulations.) *Commander. Dental Corps, ITnit@ States Navy. 463
464
JAMES
L. BRADLEY
Fig. 1.
Fig. 2. Fig. l.-Oblique fracture through the ramus at the angle of the left side of the Fig. 2.-Overlapping of the distal fragment.
mandible.
OPEX REDUCTIOK
OF FRACTURE
-&i
OB’ hIANDIBLE
(Figs. 1 and 2). The proximal fragment was displaced laterally. There was a fracture line running from bet,ween the right cuspid and first premolar to tht* inferior border of the mandiblo with no disI)l;u~emcnt .
General Physical Findings.-Physical
examination showed a well-(level oped, well-nourished young white man in mild distress. His height, was 5 frcl. 8$ inches, and weight, 385 pouuds. His bloocl pressure was 120/80 and pulse, 76. Pupils were regular, equal, and react,ed normally. There was an ecc+ymosih of the left lower eyelid. The nose was deflected t,o the left as a result. of i> The ears were essentially negative. previous injury. The throat could not I),. visualized. The chest was symmetrical and well developed. It wa.s somewh;lt There WWY no masses nor tenderness barrel-shaped with equal expansion. elicited in the abdomen. The remainder of the physical rxaminat,ion WIS IICJP:~. tive.
Fig. Z.-The
fracture
after
the extraction
of the left mandibular
molars.
Eaboratory Findings.-The blood examillat ion on adtnissioll showed 5,100?000 erythrocytes, 10,500 leukocytes of which ‘7-I per cent were polymorphonuclear neutrophils, 22 per cent were lpmphoq-tes, a.nd 4 per cent, monoq%es. Hemoglobin was 16 Gm. The Kahn was negative. The urinalysis was negative. Bleeding time showed three minutes and clottin, 0%time , seven minutes. Treatment and Course.-On Nov. 4, 1949, the day of admission, the paCent was given penicillin, 50,000 units intramuscularly every three hours, and 1 Cfm. C!odeine of sulfadiazine and 1 Gm. of sodium bicarbonate every six hours. sulfate, 1/2 gr., and aspirin, 10 gr., were prescribed for pa.in as needed. The dental int,ern on wat,ch made study models to facilitate the adaption of .lelenko arch bars.
On Nov. 5, 1949, under anesthesia, the left mandibular (Fig. 3). The first and second of the pulp and the third molar ular arch bars were secured
Fig. Fig.
I.-The 5.-Holes
displacement were drilled
2 per cent procaine regional and infiltration first, second, arxl third molars were extracted molars were removed because of rarious exposure because of displacement. Maxillary and mandibUnder with 0.020 gauge stainless steel wire. Fig.
4.
Fig.
.i.
of the fracture. for tramosseous
wiring
manual manipulation an attempt, was made to reduce t,he parts and immobilize with elast,ic traction. Repeat roentgenograms on Nov. 7, 1949, showed the teeth to be in good occlusion but the left posterior fragment of the mandible to be displaced lat,erally with diastasis at the fracture site.
It. was then decided that open rc(luc~tio~~ wol~ltl ac+complish the Ilrsircl; results. The patient w.as given pentoharbital sodinm. 0.5 (ini., the IGght. bet’ow operation and instructed not to take foo~l 01’ liclnitls aftrr t>velw o ‘(*lock miti uight. Fig.
F.
Operation.--On Nov. 8, 1949, the patient was given pentobarbita.1 sodium. 11/i gr., an hour before, and morphine sulfate, II2 gr., with atropinc sulfate. Cnder intravenous t hioperrtal l/150 gr., one-half hour before the operation. sodium and endotracheal nitrous oxide and oxygen anesthesia the patient was An incision was made through the prepared and draped in the usual manner. skin, suhcutaneons tissue, and platyma about one finger’s breadth below the
468
JAMES
Fig. Fig.
8.-Roentgenograrn of 9.-Lateral roentgenogram
the
fracture showing
I,.
BRADLEY
Fig.
8.
Fig.
9.
after reduction. the parts to be in
normal
wxi
This was -I cm. in length. The massetr? the mandiblr. muscles were ret rac%ed ~qnvar*d exposing the fract,urec! the segments were hc111 with sequestra forceps, a l/1(; a hand drill abol\t 0.5 ~1, From the fracture and Iron\ the inferior border of the mandible (Fig. 5). ,\ O.lPXl ga11gc st,a.inleis stct‘l wiri~ was insrrtetl through the holes. The t’ract,urc was then rccluced. the wirt. was twisted, cut, and bent along the body ol’ the ma~ulihlc ( b’ig. 6). Thcx deep laye~-~ were closed with catgut and the skin closed with se\-ru nmttress sutures (Fig. ‘i 1. inserted. .\ dressing was applied A rubber dam drain had been previously Following surgery the jaws were secured again with elastic traction. Postoperative healing was uneventful. The patient was continued on peniOn Nov. 9. 1949. the first postoperative da>., cillin and sulfadiazine therapy. the blood examination showed a sulfadiazine level of 7.8 mg. There were 4,810,000 erythrocytes and 9,000 leukocytes, of which 76 per carnt. were polymorphoaud 1 per cent, eosinophils. nuclear leukocytes, 23 per cent, lymphocytes, Postoperative roentgenograms of the mandible showed that, the previollsjl reported fracture through the left ra.mus at the angle had been satisfact,oril:bT reduced and maintained in position by a wire loop exteudinp through the oppo+ ing fracture edges of the mandible. There was now satisfactory apposition and alignment (Figs. 8 and 9). The mandibular first, sccontl, antI third molars hall been removed. The dressing was changed daily and the patient had been instructed ill proper oral hygiene. A high caloric and high protein liqued diet had been prescribed. The sutures were removed on Xov. 15, 1949. .Penicillin and WIfadiazine therapy was discontinued on Nov. 16, 1949. The elastics and arch bars were removed on I)ecA. 10, 1949. The teet,h were in normal occlusion. The patient, could open his mouth about 2 cm. Three days following the removal of the ligatures, he could masticate normallg. He was referred to the clinic for the restoration of carions t,ceth. On Dec. 22, 1949, he was discharged t,o duty. Postoperative roentgenograms of the mandible ou Dec. 20, 1949, shomod that the previously reported fracture fragments had been maintained in satisfactory a,pposition and alignment by the internal wire fixation. Therr \\‘i!s evidence of beginning callus formation at t\rwt time. angle of the left side of and internal pterygoid part,s (Fig. 4). While inch hole was lnade with
Comment.--Open reduction of mandibular fractures is particularly usrflll in cases where there is a marked displacement, of the posterior fragment. Transosseous wiring allows for accurate reduction and fixat,ion that ot,herwise would be difficult to manage by closed reduction. It. should be used only t,o hold t,he fragments in the reduced position so they cannot be displaced 1);~ nrust~le pull. The jaws must he immobilized by interna. fixation. Conclusion.-A Eract,nred mandible
case is reported of a diaplacecl that was tre.ated by open reduction.
post.erior
fragment
of a
OF A FRACTURE
1,. BRADLEY,
L).I).s.,
GREAT
&l.S.i).,
LAKES,
OF THE 31.%'.(
MANDIBLE
IhWP.)."
h,.
PEN reduction in the treatment of fractures of the mandible is extrcmel>. helpful in immobilizing badly displaced posterior fragment,s of the ascentling ramus. If closed reduction is not successful surgery accomplishes exact approximation of the fragments, with less displacements by abnormal musc:l~ pull. On Nov. 4, 1949, E. R. B., a ZO-year-old man, a corporal in the Cnit,ed St,aics Army, was admitted to the dental ward of the I:nited States Naval Hospital, St. Albans, Long Island, N. Y., with a diagnosis of compound fracaturr of t h(h mandible.
0
History of Present Illness.--The patient complained of pain ant1 suelliuz: at the left and right sides of the mandible dating from 8 :15 P.M. Nov. ‘1: 1MS, at which time he had been struck in the jaw by another man. While in his company barracks, the patient had given orders to another man, who struck him instead of carrying out the order. He reported to the Fort, I)ix, N. .I .. He was then sent. to the base hospital dispensary where he was examined. where roentgenograms were taken and he was placed on penicillin therapy. t1e was then transported to this activity via ambulance and admit,ted. Past History.-His past history was entirely irrelevant. He had the scarlet fever, which he said had c21us~cl usual childhood diseases, including deafness for about six years. He had sustainetl a fl~actured nose five ywr~ previously while playing football. Family History.-The patient’s father and mother were living ant1 weil. He had two sisters and three brothers who were living ant1 well. ( )IIC: l)rotll+t~ had arrested tuberculosis. Examination.-Examination revealed ecchymosis of the lower lid of the left eye and a swelling at the angle of the left side of the mandiblr extentlittg from the zygomatic arch to below the angle. The right side near the mrntnl area was slightly swollen. The motion of the jaw was limited. He could opc’n his mouth about 0.5 cm. with marked pain in the left mandibular third mvlal region. Oral hygiene was extremely poor with numerous carious teeth. ‘l’hc~rc The mandibular third molar was was a foul odor to the patient’s breath. elongated and loose. There was numbness of the distribution of the inierior alveolar nerve. Roentgenograms of the mandible showed an oblique fracture through the ramus at the angle of the left side of the mandible extending from the base of There was considerable diaphysis between the frapme~rts t,he third molar. The opinions or assertions contained herein are the private ones of the writer and not to be construed as official or reflecting the views of the Navy Department or the Naval Service at large. (Art. 13 [2] U. S. Navy Regulations.) *Commander. Dental Corps, ITnit@ States Navy. 463
464
JAMES
L. BRADLEY
Fig. 1.
Fig. 2. Fig. l.-Oblique fracture through the ramus at the angle of the left side of the Fig. 2.-Overlapping of the distal fragment.
mandible.
OPEX REDUCTIOK
OF FRACTURE
-&i
OB’ hIANDIBLE
(Figs. 1 and 2). The proximal fragment was displaced laterally. There was a fracture line running from bet,ween the right cuspid and first premolar to tht* inferior border of the mandiblo with no disI)l;u~emcnt .
General Physical Findings.-Physical
examination showed a well-(level oped, well-nourished young white man in mild distress. His height, was 5 frcl. 8$ inches, and weight, 385 pouuds. His bloocl pressure was 120/80 and pulse, 76. Pupils were regular, equal, and react,ed normally. There was an ecc+ymosih of the left lower eyelid. The nose was deflected t,o the left as a result. of i> The ears were essentially negative. previous injury. The throat could not I),. visualized. The chest was symmetrical and well developed. It wa.s somewh;lt There WWY no masses nor tenderness barrel-shaped with equal expansion. elicited in the abdomen. The remainder of the physical rxaminat,ion WIS IICJP:~. tive.
Fig. Z.-The
fracture
after
the extraction
of the left mandibular
molars.
Eaboratory Findings.-The blood examillat ion on adtnissioll showed 5,100?000 erythrocytes, 10,500 leukocytes of which ‘7-I per cent were polymorphonuclear neutrophils, 22 per cent were lpmphoq-tes, a.nd 4 per cent, monoq%es. Hemoglobin was 16 Gm. The Kahn was negative. The urinalysis was negative. Bleeding time showed three minutes and clottin, 0%time , seven minutes. Treatment and Course.-On Nov. 4, 1949, the day of admission, the paCent was given penicillin, 50,000 units intramuscularly every three hours, and 1 Cfm. C!odeine of sulfadiazine and 1 Gm. of sodium bicarbonate every six hours. sulfate, 1/2 gr., and aspirin, 10 gr., were prescribed for pa.in as needed. The dental int,ern on wat,ch made study models to facilitate the adaption of .lelenko arch bars.
On Nov. 5, 1949, under anesthesia, the left mandibular (Fig. 3). The first and second of the pulp and the third molar ular arch bars were secured
Fig. Fig.
I.-The 5.-Holes
displacement were drilled
2 per cent procaine regional and infiltration first, second, arxl third molars were extracted molars were removed because of rarious exposure because of displacement. Maxillary and mandibUnder with 0.020 gauge stainless steel wire. Fig.
4.
Fig.
.i.
of the fracture. for tramosseous
wiring
manual manipulation an attempt, was made to reduce t,he parts and immobilize with elast,ic traction. Repeat roentgenograms on Nov. 7, 1949, showed the teeth to be in good occlusion but the left posterior fragment of the mandible to be displaced lat,erally with diastasis at the fracture site.
It. was then decided that open rc(luc~tio~~ wol~ltl ac+complish the Ilrsircl; results. The patient w.as given pentoharbital sodinm. 0.5 (ini., the IGght. bet’ow operation and instructed not to take foo~l 01’ liclnitls aftrr t>velw o ‘(*lock miti uight. Fig.
F.
Operation.--On Nov. 8, 1949, the patient was given pentobarbita.1 sodium. 11/i gr., an hour before, and morphine sulfate, II2 gr., with atropinc sulfate. Cnder intravenous t hioperrtal l/150 gr., one-half hour before the operation. sodium and endotracheal nitrous oxide and oxygen anesthesia the patient was An incision was made through the prepared and draped in the usual manner. skin, suhcutaneons tissue, and platyma about one finger’s breadth below the
468
JAMES
Fig. Fig.
8.-Roentgenograrn of 9.-Lateral roentgenogram
the
fracture showing
I,.
BRADLEY
Fig.
8.
Fig.
9.
after reduction. the parts to be in
normal
wxi
This was -I cm. in length. The massetr? the mandiblr. muscles were ret rac%ed ~qnvar*d exposing the fract,urec! the segments were hc111 with sequestra forceps, a l/1(; a hand drill abol\t 0.5 ~1, From the fracture and Iron\ the inferior border of the mandible (Fig. 5). ,\ O.lPXl ga11gc st,a.inleis stct‘l wiri~ was insrrtetl through the holes. The t’ract,urc was then rccluced. the wirt. was twisted, cut, and bent along the body ol’ the ma~ulihlc ( b’ig. 6). Thcx deep laye~-~ were closed with catgut and the skin closed with se\-ru nmttress sutures (Fig. ‘i 1. inserted. .\ dressing was applied A rubber dam drain had been previously Following surgery the jaws were secured again with elastic traction. Postoperative healing was uneventful. The patient was continued on peniOn Nov. 9. 1949. the first postoperative da>., cillin and sulfadiazine therapy. the blood examination showed a sulfadiazine level of 7.8 mg. There were 4,810,000 erythrocytes and 9,000 leukocytes, of which 76 per carnt. were polymorphoaud 1 per cent, eosinophils. nuclear leukocytes, 23 per cent, lymphocytes, Postoperative roentgenograms of the mandible showed that, the previollsjl reported fracture through the left ra.mus at the angle had been satisfact,oril:bT reduced and maintained in position by a wire loop exteudinp through the oppo+ ing fracture edges of the mandible. There was now satisfactory apposition and alignment (Figs. 8 and 9). The mandibular first, sccontl, antI third molars hall been removed. The dressing was changed daily and the patient had been instructed ill proper oral hygiene. A high caloric and high protein liqued diet had been prescribed. The sutures were removed on Xov. 15, 1949. .Penicillin and WIfadiazine therapy was discontinued on Nov. 16, 1949. The elastics and arch bars were removed on I)ecA. 10, 1949. The teet,h were in normal occlusion. The patient, could open his mouth about 2 cm. Three days following the removal of the ligatures, he could masticate normallg. He was referred to the clinic for the restoration of carions t,ceth. On Dec. 22, 1949, he was discharged t,o duty. Postoperative roentgenograms of the mandible ou Dec. 20, 1949, shomod that the previously reported fracture fragments had been maintained in satisfactory a,pposition and alignment by the internal wire fixation. Therr \\‘i!s evidence of beginning callus formation at t\rwt time. angle of the left side of and internal pterygoid part,s (Fig. 4). While inch hole was lnade with
Comment.--Open reduction of mandibular fractures is particularly usrflll in cases where there is a marked displacement, of the posterior fragment. Transosseous wiring allows for accurate reduction and fixat,ion that ot,herwise would be difficult to manage by closed reduction. It. should be used only t,o hold t,he fragments in the reduced position so they cannot be displaced 1);~ nrust~le pull. The jaws must he immobilized by interna. fixation. Conclusion.-A Eract,nred mandible
case is reported of a diaplacecl that was tre.ated by open reduction.
post.erior
fragment
of a